How to Manage Population Health Effectively in Accountable Care Organizations

PHYTEL | WHITEPAPER
Managing Population Health Effectively
in Accountable Care Organizations

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com2 Copyright ©2015 Phytel Inc. All rights reserved.
Introduction
The Affordable Care Act authorized a Medicare shared-savings program for accountable care organizations, and private
payers are also contracting with ACOs. To succeed, ACOs must learn how to manage population health effectively.
The ACO Environment
Physicians and hospitals, which are competing for leadership of ACOs, must find ways to share revenue equitably within
these organizations. While payers don’t want to push risk on providers too rapidly, some advanced ACOs have already
accepted global capitation contracts.
Group Practice Demonstration
Medicare’s Physician Group Practice demonstration, a precursor of the ACO shared-savings program, offers some
lessons about how large groups can approach this reimbursement method. The results show that it was easier for the
participating groups to improve quality than to generate shared savings.

Population Health Management
ACOs have strong incentives to improve population health to meet quality goals and reduce costs. To do that, they
must stress non-visit care and disease management, build care teams, and work with patients to improve their health
behavior.
Role of Information Technology
Population health management requires clinical integration, which cannot exist without a robust IT infrastructure. In
addition, a range of automation tools are needed for cost-effective care management and outreach to patients. When
coupled with care transformation services, information technology is most effective for scaling the reach of the care team
across the ACO cohort(s) and lays the foundation for managing population health.

Conclusion
Notes
Contents
Page 3
Page 5
Page 7
Page 8
Page 9
Page 11
Page 12

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com Copyright ©2015 Phytel Inc. All rights reserved. 3
Introduction
The Patient Protection and Affordable Care Act (PPACA) of 2010 focuses mainly on regulating health insurance
and expanding coverage. But the legislation also addresses the role of the health-care delivery system in health
spending growth.
In this area, the law’s major thrust is to change how providers are paid. Among the approaches that
Congress authorized the government to undertake is one that involves “accountable care organizations”
(ACOs), which are health-care provider groups that are designed to be accountable for the cost and
quality of care.
Specifically, the PPACA authorized the Centers for Medicare and Medicaid Services (CMS) to launch a
shared-savings program with ACOs in 2012. Under this approach, an ACO that meets specified quality
goals can split with CMS any savings that surpass a minimum level.1
ACOs that participate in the Medicare Shared Savings Program must consist of providers that “work
together to manage and coordinate care for Medicare fee-for-service beneficiaries.” Among the ACOs
in the MSSP are organizations based on individual practice networks, group practices, partnerships of
hospitals and physicians, hospitals and their employed doctors, and federally qualified health centers.
ACOs must meet thresholds on thirty-three quality measures and save more than a minimum amount to
qualify for payments equal to 50 percent of the amount they save CMS above a benchmark related to
their historical performance. A few ACOs have elected to take downside risk as well, in return for a higher
percentage of savings.2
The Medicare Shared-Savings Program, which is not a pilot, potentially affects all patients covered by
traditional Medicare. As a result, the ACO provision has generated strong interest among group practices
and health-care organizations.
The ACO initiatives of some commercial insurers are also attracting attention from providers. Some of the
private ACO contracts involve financial risk,3
and others are limited to gainsharing. But the majority of the
600 current ACOs are involved in the MSSP and other CMS programs.4,5
The Medicare Shared-Savings
Program, which is not a pilot,
potentially affects all patients
covered by traditional Medicare.
As a result, the ACO provision has
generated strong interest among
group practices and health-care
organizations.

In the first year of the MSSP, fifty-four of the
114 participants that joined the program
in 2012 had total costs that fell below their
budget benchmarks, but only twenty-nine
reduced spending enough to qualify for a
total of $126 million in shared savings. The
other sixty ACOs generated costs above
their benchmarks.6
Other New Reimbursement
Methods
The ACO concept dovetails with other new
reimbursement methods that payers are
piloting, including payment bundling and
patient-centered medical homes. Further
down the road, it’s likely that shared savings
will transition to some type of payment
bundling and, eventually, global capitation
(a fixed payment for all care provided to
each patient). But right now, the government
and private insurers are proceeding with
caution, because they know that the vast
majority of providers are not ready to
assume that much financial risk. Moreover,
there are questions about how much
limitation on provider choice the public is
willing to accept.
Whichever direction the reimbursement
changes take, they will require providers
to do population health management
(PHM). In the case of ACOs, the reasons
are transparent: these organizations must
manage the full spectrum of care and
must be accountable for a defined patient
population.7
Unless an ACO is capable of
tracking the health status of and the care
provided to every one of its patients, it is
unlikely to produce significant savings or
meet the quality benchmarks of CMS. And
when organizations take on financial risk, it
is absolutely essential for them to learn how
to prevent illness and manage care as well
as possible. The more risk that providers
assume, the better they have to be at
managing their populations’ health.
Unless an ACO
is capable of
tracking the health
status of and the
care provided
to every one of
its patients, it is
unlikely to produce
significant savings
or meet the quality
benchmarks of
CMS.

The ACO Environment
A growing number of health-care organizations have partnered with health plans to implement ACOs.8
While most
insurance companies are still reluctant to offer global capitation contracts, they see opportunities in working with
ACOs to lower costs and improve quality.
Meanwhile, hospitals and doctors that are partnered in ACOs must find ways to share revenue. But
gainsharing between hospitals and physicians is still fairly uncommon, having only recently emerged
from a regulatory deep freeze.9
In addition, health policy expert Jeff Goldsmith points out,10
hospitals and
independent physicians have moved further apart in recent years as medical and surgical specialists have
pulled more services out of the hospital into their offices, imaging centers, and ambulatory surgery centers.
Other trends are moving in the opposite direction. Hospitals are employing more and more physicians,
including specialists.11
They are doing so partly for competitive reasons and partly because they believe
that they will need to have physicians’ cooperation when reimbursement methods change.
The Federal Trade Commission, meanwhile, has given a handful of IPAs and physician-hospital
organizations (PHOs) approval to negotiate insurance contracts because they are clinically integrated and
are therefore able to improve the quality of care.12
Many health-care systems are moving toward clinical
integration with their physicians, whether or not the latter are employed. And the spread of health-care
information technology is expected to accelerate this process.13
Snapshot of Current ACOs
Currently, the biggest private-sector ACO experiment is the “alternative quality contract” of
Massachusetts Blue Cross and Blue Shield.14
This is actually a global capitation agreement, with two
features that differentiate it from the old HMO risk contracts: first, participants can qualify for graduated
quality incentives, and second, the insurer pledges not to reduce their budgets in future years. In return,
the contract holders promise to gradually cut cost growth to the rate of inflation.
Sixteen organizations currently participate in the Massachusetts Blues’ alternative quality contract. They
range in size from Partners Healthcare in Boston to the physician-hospital organization of Lowell General
Hospital in Lowell, Massachusetts.15
Meanwhile, hospitals and doctors
that are partnered in ACOs must
find ways to share revenue... while
both physician organizations and
hospitals would prefer to be in
charge, they will have to learn how
to work together.

Other organizations that have formed ACOs
include the Greater Rochester (NY) IPA,
Advocate Health Care in Chicago, Brown &
Toland in San Francisco, Hill Physicians in
San Ramon, Calif., and Healthcare Partners
in Los Angeles.
Hill Physicians is participating in a three-
way pilot involving Dignity Health and Blue
Shield of California.16
That pilot, funded by
the California Public Employees Retirement
System, is focused on reducing HMO costs
by sharing financial risk.
Healthcare Partners, a multistate physician
group and IPA based in Los Angeles, is
engaged in another ACO pilot with Anthem
Blue Cross. This pilot started with a shared-
savings approach in the first year, but was
expected to graduate to global capitation
over the five-year contract period.17
The Anthem-Healthcare Partners venture
is one of several pilots being conducted
across the country under the aegis of the
Engelberg Center for Health Care Reform at
the Brookings Institution and the Dartmouth
Institute for Health Policy and Clinical
Practice. The leaders of those research
organizations—Mark McClellan, MD, and
Elliott Fisher, MD, respectively—are among
the founders of the ACO movement. They
formed the Brookings-Dartmouth ACO
Learning Network to promote the concept
to health-care organizations.18
Some observers question whether ACOs
can succeed in most areas unless hospitals
take the lead in organizing them. Yet
there is nothing in the CMS regulations
that requires hospitals to lead or even
be a direct participant in ACOs. The
only requirements are that ACOs include
primary care physicians and serve at
least 5,000 Medicare patients each.19 But
because an ACO must coordinate care
across all care settings, it must secure the
cooperation of one or more hospitals. So,
while both physician organizations and
hospitals would prefer to be in charge, they
will have to learn how to work together.
Other experts doubt that a shared-savings
program that offers only rewards without
risk will get physicians’ attention and
motivate them to change how they practice.
They also wonder how patients will react
to the idea of having a personal physician
coordinate all of their care, when the
patients are used to going to any physician
they want to see. These observers view the
Medicare approach as a first step toward
partial or full capitation of health-care
organizations.20

Group Practice Demonstration
These are valid points, but the history of Medicare’s Physician Group Practice (PGP) demonstration—an
important precursor of the shared-savings program—offers some reasons to hope that large provider groups will
be able to use CMS’s shared-savings approach in constructive ways.
The PGP pilot, which involved ten large groups and health-care systems, began in 2005 and ended in March
2010. CMS paid the participants up to 80 percent of Medicare’s savings from inpatient and outpatient care in
excess of 2 percent of historical costs. Half of the bonuses were based on efficiency, and the other half came
from meeting quality targets.
Over the five years of the PGP demonstration, the groups did well on CMS’s quality measures. In the fifth year,
seven groups achieved benchmark-level performance on all thirty-two measures, and the other groups did
so on at least thirty measures. In addition, the PGPs increased their quality scores on diabetes, heart-failure,
and cancer-screening measures by at least 9 percentage points over the five years.
However, only half of the PGP participants were able to exceed a 2 percent savings threshold after three
years. The Marshfield Clinic alone earned about half of the total savings, and four other groups accounted for
most of the rest.21
Each participant used different techniques to improve care and reduce costs. For example, the Dartmouth-
Hitchcock Clinic in Bedford, New Hampshire, focused on the use of electronic registries and patient
education. The Everett Clinic, a large multispecialty group in Washington state, concentrated on improving
primary care and radiology services, as well as the handoffs between inpatient and outpatient care settings.
But all of the participants, in their own ways, were trying to upgrade their ability to manage population health.
The Everett Clinic netted some of the shared savings in the second year of the pilot, but none in the third
year. The group successfully reduced the cost of imaging services and improved its understanding of how to
manage high-cost subpopulations who need complex care. But the clinic also encountered some significant
obstacles, including difficulty in correlating health risk scores with cost-effectiveness, the retrospective nature
of the model, problems in getting providers outside the group to cooperate, and difficulty in persuading
patients to use their primary care physician as a care coordinator.22
Each participant used different
techniques to improve care
and reduce costs. But all of the
participants, in their own ways,
were trying to upgrade their ability
to manage population health.

Population Health Management
US health care costs much more per capita than the systems of other advanced countries but does not deliver better
results.23
The reasons are well-known: The United States has a fragmented, chaotic care delivery system, health-care
providers are incentivized to provide high service volume rather than high-quality care, we have too few primary care
physicians and too many specialists, and our system is provider-centered rather than patient-centered.24
To turn this bloated, wasteful health-care system around, policy makers and health-policy experts are
focusing on population health management (PHM). PHM has been defined as a health-care approach that
emphasizes “the health outcomes of individuals in a group and the distribution of outcomes in that group.”
It addresses not only longitudinal care across the continuum of care, but also personal health behavior
that may contribute to the evolution or exacerbation of diseases.25
Among the key characteristics of health organizations that conduct PHM are an organized system of
care; the use of multidisciplinary care teams; coordination across care settings; enhanced access to
primary care; centralized resource planning; continuous care, both in and outside of office visits; patient
self-management education; a focus on health behavior and lifestyle changes; the use of interoperable
electronic health records; and the use of registries and other tools essential to the automation of PHM.26
Today the main practitioners of PHM are group-model HMOs, large integrated delivery systems, the
Veterans Affairs health system, and the Military Health System. But as ACOs gain traction, the providers
that belong to them are increasingly trying to manage population health, too.
Whether the financial incentive is shared savings or global budgets, ACOs have a strong motive to
maintain health, prevent disease, and control chronic conditions so that they don’t lead to ER visits and
hospitalizations. To achieve these goals, ACOs have to stress non-visit care and disease management,
including home monitoring of the sickest patients. They have to build care teams that are capable of
tracking patients’ health status and ensuring that they receive recommended care. And they have to
incentivize providers to work with patients to improve their health behavior and their compliance with
care plans.
ACOs share many of these objectives with patient-centered medical homes. For example, a physician
whose practice serves as a medical home must coordinate care, improve patient self-management
skills, track the services provided to patients, and maintain contact with patients between visits. Medical
homes also use electronic tools such as EHRs and registries.27
The primary care practices that serve as
medical homes are generally much smaller than ACOs and may lack the ability to induce specialists and
hospitals to cooperate with them.28
Nevertheless, a practice that qualifies as a medical home has gone a
long way toward being able to function within an ACO.
An effective ACO must not only take excellent care of patients who present for care, but must also try to
monitor and stay in contact with people who do not have contact, or rarely have contact, with health-care
providers. The importance of communicating with this segment of the population is profound, because it
includes many individuals who are or will become sick and need acute or chronic care at some point in
time. Therefore, an ACO that proactively addresses the health needs of this cohort will be able to control
costs better than one that doesn’t.

Role of Information Technology
To be successful, an ACO must be clinically integrated, which means that physicians and other providers must
communicate and exchange key clinical information with each other. Until recently, this was very difficult, because
most clinical data were locked up in paper files that were inaccessible to providers outside of a particular hospital
or practice. Even the delivery of lab results was still done mostly by fax, courier, or mail. Now, as EHRs become
widespread because of the government’s Meaningful Use incentive program, all of this is starting to change. In
addition, care transformation services that help integrate information technology into daily work flow can be effective
at driving clinical integration and population health management.
EHRs are crucial to clinical integration. Not only can they make it easier for caregivers to document and
retrieve patient data, but they also hold the key to health information exchange with other providers—if
they ever become interoperable.
Despite the enormous increase in the amount of digitized health information, however, most EHRs are
still incapable of exchanging structured data. The clinical summaries that certified EHRs must be able to
exchange in Meaningful Use stage 2 use a specially formatted document known as the consolidated CDA
(C-CDA). EHRs from different vendors can exchange these summaries, but the data in them cannot flow
into the data fields in electronic charts.
The federal government has spent more than half a billion dollars to help states develop health information
exchanges (HIEs). While it’s not clear that this effort has substantially improved the ability of providers
to exchange patient data, a recent report shows that in 2013, more than six in ten hospitals exchanged
health information with outside providers—a 51 percent increase since 2008. Fifty seven percent of
hospitals exchanged data with ambulatory providers outside of their system—although only about
a quarter of hospitals notified outside primary care providers when their patients entered one of the
hospitals’ ERs.29
Meanwhile, as the federal grants expire, regional HIEs are still searching for a business model,30
and an
increasing number of health-care organizations are building private exchanges.31
Clinician-to-clinician
messaging using the Direct secure-messaging protocol is also growing as the Direct infrastructure
evolves.32
Among the key characteristics of health organizations that conduct PHM
are an organized system of care; the use of multidisciplinary care teams;
coordination across care settings; enhanced access to primary care;
centralized resource planning; continuous care, both in and outside of office
visits; patient self-management education; a focus on health behavior and
lifestyle changes; the use of interoperable electronic health records; and the
use of registries and other tools essential to the automation of PHM.

Supplemental
technologies
can aid ACOs
in managing
population health at
the macro level. For
example, an entire
patient population
could be filtered
by payer, activity
center, provider,
health condition,
and care gaps.
The same filters
could be applied to
all patients with a
particular condition
to find out where
the ACO needs to
improve its care for
that disease.
Automation Tools
EHRs have some drawbacks as tools for
performing population health management.
They are not designed for tracking
populations, providing actionable reports on
care gaps, or sending alerts to patients.33
ACOs will need not only EHRs, but also
supplemental technologies that automate
the work of monitoring, educating, and
maintaining contact with the patient
population.
These tools, which should be used in
conjunction with EHRs, include electronic
registries, multiple outreach and
communications methods, software that can
stratify a population by health status, and
health risk assessment programs that trigger
alerts and provide educational materials to
patients. Automated PHM tools ensure that
the routine, repetitive work of managing
population health is done in the background,
freeing up doctors and nurses to do the work
that only they can do.
For example, registries can be programmed
to generate reports on the care gaps of
patients for care coordinators and care
managers in practices. The care managers
can use the information to prepare care
teams for patient visits and to ensure that
patients are receiving recommended services
across the continuum of care. By automating
patient communications, registries combined
with outreach tools also make it easy to send
alerts to every patient who needs to be seen
for follow-up.
These supplemental technologies can also
aid ACOs in managing population health
at the macro level. A sophisticated rules
engine can integrate disparate types of data
with evidence-based guidelines, generating
reports that provide many different views
of the information. For example, the entire
patient population could be filtered by payer,
activity center, provider, health condition, and
care gaps. The same filters could be applied
to all patients with a particular condition to
find out where the ACO needs to improve its
care for that disease.
ACO management could also use this type of
information to pinpoint where the coordination
of care is breaking down. For example, if an
unusual number of patients with a particular
condition were being readmitted to the
hospital, that might indicate a problem with
outpatient follow-up.
Another important determinant of population
health is the degree to which patients are
coached on improving their health behavior.
Automation tools can also help in this area.
For example, when a patient fills out a health
risk assessment online or in a practice
computer kiosk, that patient can receive
educational materials tailored to his or her
condition and can be directed to appropriate
self-help programs for, say, smoking
cessation or losing weight.

Conclusion
Largely because of the health-care reform law’s authorization of a Medicare shared-savings program,
accountable care organizations (ACOs) are generating excitement among health-care providers. If ACOs
become widespread, they could become a powerful force for establishing population health management as the
primary approach to quality improvement and cost containment in the United States.
To do PHM properly, ACOs must use a range of information technologies. These include not only electronic
health records, but also supplemental applications that automate the routine work of tracking, educating, and
communicating with patients. These tools make it possible to do PHM comprehensively and cost-effectively,
allowing ACO members to benefit economically from shared-savings, bundled-payment, and global-capitation
programs.
Many health-care organizations are setting up ACOs. But only the ACOs that achieve clinical integration and
learn how to do population health management will succeed. Therefore, information technologies, including
automation tools, are essential components of ACO success.

1. Kaiser Family Foundation, “Summary of New Health Reform Law,” accessed at
http://www.kff.org/healthreform/upload/8061.pdf.
2. CMS, “Shared Savings Program,” accessed at http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/sharedsavingsprogram/index.html.
3. Blue Shield of California press release, “Blue Shield of California, Catholic Healthcare West & Hill
Physicians Medical Group to Pilot Innovative New Care Model for CalPERS,” April 22, 2009.
4. Leavitt Partners Center for Accountable Care Intelligence. http://healthaffairs.org/blog/2014/01/29/
accountable-care-growth-in-2014-a-look-ahead/.
5. Molly Gamble, “Total Number of ACOs Tops 520,” Beckers Hospital Review, April 24, 2014, accessed
at http://www.beckershospitalreview.com/accountable-care-organizations/total-number-of-acos-
tops-520.html.
6. S. Lawrence Kocot, Farzad Mostashari, and Ross White, “Year One Results from Medicare Shared
Savings Program: What It Means Going Forward,” Brookings Institution Upfront blog, Feb. 7, 2014.
7. Jordan T. Cohen, “A Guide to Accountable Care Organizations, and Their Role in the Senate’s
Health Reform Bill,” Health Reform Watch, March 11, 2010, accessed at
http://www.healthreformwatch.com/2010/03/11/a-guide-to-accountable-care-organizations-and-their-
role-in-the-senates-health-reform-bill/.
8. Ibid.
9. Ken Terry, “Gainsharing Is Becoming More Respectable,” BNET Healthcare, July 28, 2009, accessed
at http://industry.bnet.com/healthcare/1000908/gainsharing-is-becoming-more-respectable/?utm_
source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bnet%2Fhealthcare+%28BNET+
Industries+-+Healthcare+Insights%29.
10. Jeff Goldsmith, “The Accountable Care Organization: Not Ready For Prime Time,” Health Affairs Blog,
August 17, 2009, accessed at http://healthaffairs.org/blog/2009/08/17/the-accountable-care-
organization-not-ready-for-prime-time/.
11. Ken Terry, “Physician Alignment,” Hospitals & Health Networks, September 2009, accessed
at http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/
data/09SEP2009/0909HHN_CoverStory_Alignment&domain=HHNMAG.
12. Gregg Blesch, “FTC Offers Clearer Guidance on Clinical Integration Agreements,” Modern
Physician.com, April 27, 2009, accessed at HYPERLINK “http://www.modernphysician.com/apps/
pbcs.dll/article?AID=/20090427/MODERNPHYSICIAN/304199990”http://www.modernphysician.com/
apps/pbcs.dll/article?AID=/20090427/MODERNPHYSICIAN/304199990#.
13. “Online Connectivity: Linking Providers and Patients to Create a Community of Care,” Patient
Safety & Quality Healthcare, January/February 2010, accessed at http://www.psqh.com/
januaryfebruary-2010/391-online-connectivity.html.
14. Ken Terry, “Global Capitation—It’s Back,” Physicians Practice, April 2009, accessed at http://www.
physicianspractice.com/index/fuseaction/articles.details/articleID/1313.htm.
15. Blue Cross Blue Shield of Massachusetts, “Alternative Quality Contract,” accessed at http://www.
bluecrossma.com/visitor/about-us/affordability-quality/aqc.html.
16. Blue Shield of California press release, “Blue Shield of California, Catholic Healthcare West & Hill
Physicians Medical Group”…
Notes

17. Josette N. Gbemudu, Bridget K. Larson, Aricca D. Van Citters, Sara A. Kreindler, Frances M.
Wu, Eugene C. Nelson, Stephen M. Shortell, and Elliott S. Fisher, “Healthcare Partners: Building
on a Foundation of Global Risk Management to Achieve Accountable Care,” Commonwealth Fund
case study, January 2012, accessed at http://www.commonwealthfund.org/~/media/Files/Publications/
Case%20Study/2012/Jan/1572_Gbemudu_HealthCare_Partners_case%20study_01_17_2012.pdf.
18. Brookings-Dartmouth ACO Learning Network, home page at https://xteam.brookings.edu/bdacoln/
Pages/home.aspx.
19. Patient Protection and Affordable Care Act, H.R. 3590, Sec. 3022 (Medicare Shared Savings
Program).
20. Berkeley Center on Health, Economic, & Family Security, “Implementing Accountable Care
Organizations,” Executive Summary, accessed at http://www.law.berkeley.edu/files/chefs/
Implementing_ACOs_May_2010.pdf.
21. Gail Wilensky, “Lessons from the Physician Group Practice Demonstration—a Sobering Reflection,”
New England Journal of Medicine 365 (2011): 1659–1661.
22. Harold Dash, MD, “The Everett Clinic’s Journey to an Accountable Care Organization,” slide
presentation, American Medical Group Association Northwest Regional Meeting, June 4, 2010.
23. The Commonwealth Fund, “Mirror, Mirror on the Wall: How The Performance of the U.S. Health Care
System Compares Internationally, 2010 Update,” accessed at http://www.commonwealthfund.org/
Content/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx.
24. Institute of Medicine, Crossing the Quality Chasm. Washington, DC: National Academy Press, 2001.
25. David M. Lawrence, “How to Forge a High-Tech Marriage Between Primary Care and Population
Health,” Health Affairs, May 2010, 1004–1009.
26. David M. Lawrence, From Chaos to Care: The Promise of Team-Based Medicine. Cambridge, MA:
Da Capo Press, 2003.
27. AAFP, AAP, ACP, AOA, “Joint Principles of the Patient-Centered Medical Home,” February 2007,
accessed at http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home.
28. Paul A. Nutting, MD, MSPH; William L. Miller, MD, MA; Benjamin F. Crabtree, PhD; Carlos Roberto
Jaen, MD, PhD; Elizabeth E. Stewart, PhD; and Kurt C. Stange, MD, PhD, “Initial Lessons from the
First National Demonstration Project on Practice Transformation to a Patient-Centered Medical
Home,” Annals of Family Medicine 7 (2009): 254–260.
29. Greg Slabodkin, “HIE Among Hospitals Grows, Still Needs Improvement,” Health Data Management,
May 6, 2014, accessed at http://www.healthdatamanagement.com/news/HIE-Among-Hospitals-
Needs-Improvement-47997-1.html?utm_campaign=daily-may%206%202014&utm_
medium=email&utm_source=newsletter&ET=healthdatamanagement%3Ae2629612%3A3696614a%
3A&st=email.
30. Julia Adler-Milstein, David W. Bates, and Ashish K. Jha, “Operational Health Information Exchanges
Show Substantial Growth, But Long-Term Funding Remains a Concern,” Health Affairs 32, no. 8
(August 2013): 1486–1492.
31. Ken Terry, “KLAS: ‘Private’ HIEs Leaving ‘Public’ HIEs in the Dust,” FierceHealthIT, July 8, 2011,
accessed at http://www.fiercehealthit.com/story/klas-private-hies-leaving-public-hies-dust/2011-07-08.
32. HIT Trends blog, April 2014, accessed at http://www.directtrust.org/storage/post-images/HIT%20
Trends%20April%202014.pdf.
33. Rushika Fernandopulle and Neil Patel, “How the Electronic Health Record Did Not Measure Up to the
Demands of Our Medical Home Practice,” Health Affairs, April 2010, 622–628.

How to Manage Population Health Effectively in Accountable Care Organizations

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to How to Manage Population Health Effectively in Accountable Care Organizations

Similar to How to Manage Population Health Effectively in Accountable Care Organizations (20)

More from Phytel

More from Phytel (13)

Recently uploaded

Recently uploaded (20)

How to Manage Population Health Effectively in Accountable Care Organizations